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1 Risk behaviour, sexually transmitted infections and HIV among long-distance truck drivers: a cross-sectional survey along national highways in India Arvind Pandey a, Sudhir Kumar Benara a, Nandini Roy a, Damodar Sahu a, Mariamma Thomas a, Dhirendra Kumar Joshi a, Utpal Sengupta a, Ramesh S. Paranjape b, Aparajita Bhalla c and Ajay Prakash d, for the IBBA Study Team M Objective: To report HIV and sexually transmitted infection (STI) prevalence and sexual behaviour of long-distance truckers on four national highway routes from a large, cross-sectional, national-level trucker survey in India. Methods: Seven trans-shipment locations covering the bulk of India s transport volume along four routes, north-west (NW), north-south (NS), north-east (NE) and south-east (SE) were identified as survey sites. A total of 2066 long-distance truckers were selected using a two-stage, time location cluster sampling approach and, after consent, interviewed about their sexual behaviour. Urine and blood sample were tested for selected STIs. Results: Overall, HIV prevalence among truckers was found to be 4.6%, with prevalence highest on the SE route (6.8%) and lowest on the NS (2.4%). Positive HSV-2 serology, which was tested in a 10% subsample, was low along three routes, 10.0%, 12.8% and 6.7% for the NE, NS and NW, respectively, but 38.7% in the SE. The truckers from the SE were found to be more likely to have sex with paid partners than the NE route. Moreover, truckers who owned their trucks were more likely than those who did not use condoms consistently with paid partners, and truckers who drive trucks owned by their relatives/friends are more likely than others to have any STI. Conclusions: Low self-risk perception for HIV (9.9%), low consistent condom use with non-paid partners (18.6%) and wives (3%), low reported exposure to any interventions (25.6%) and low levels of ever having taken an HIV test (16.5%) make truckers an important bridge population requiring strengthened interventions. ß 2008 Wolters Kluwer Health Lippincott Williams & Wilkins AIDS 2008, 22 (suppl 5):S81 S90 Keywords: AIDS, condom use, HIV, long-distance truck drivers, risk behaviour, sexually transmitted infecton, unsafe sex a National Institute of Medical Statistics, New Delhi, India, b National AIDS Research Institute, Pune, India, c Bill and Melinda Gates Foundation, New Delhi, India, and d Family Health International, New Delhi, India. Correspondence to Arvind Pandey, National Institute of Medical Statistics, Indian Council of Medical Research, Ansari Nagar, New Delhi , India. Members of the IBBA study team are listed at the end of the paper. ISSN Q 2008 Wolters Kluwer Health Lippincott Williams & Wilkins S81

2 S82 AIDS 2008, Vol 22 (suppl 5) Introduction India has a large trucking population estimated at 5 6 million truckers and helpers, and approximately 3.5 million are classified as long-distance truckers [1]. The trucking industry in India is largely unorganized and almost entirely in the private domain, structured around a loose system comprising truck operators, intermediaries and users. In the late 1990s, almost 77% of India s truck fleet was owned by operators with no more than five trucks, whereas only approximately 6% of trucks were owned by operators with more than 20 trucks [2]. This ownership profile created middlemen on whom small trucking operators depend to generate business. The predominance of middlemen and small operators has undermined the visibility of the industry to transport planners and policy-makers [3,4]. The sexual behaviour of trucking populations has been associated with the transmission of sexually transmitted infections (STI) and HIV in India and elsewhere in Asia, Africa, south America and the United States [1 14]. HIV prevention interventions have often focused on truckers because of their high-risk behaviour, mobility and ability to spread infections to new geographical areas [5,8,15]. Most studies related to STI, HIV and risk behaviour among both long and short-distance truckers in India have focused primarily on specific regions with small samples [15 19]. Those limited data confirm their frequency of commercial sex and other high-risk behaviours. HIV prevention interventions have thus focused on truckers in India since 1996, with funding from the Department for International Development (DFID) and the National AIDS Control Programme [20]. Long-distance truckers are a target population for Avahan, the India AIDS Initiative s HIV prevention strategy [21]. This paper reports findings from the first-ever, comprehensive cross-sectional survey of long-distance truckers along four Indian national highway routes, with a biological component. Methodology The methods for the survey, termed the Integrated Biological and Behavioural Assessment (IBBA) are described in another paper in this supplement. This paper will briefly reiterate them here, focusing on the unique aspects of the sampling. IBBA among longdistance truck drivers was undertaken between June and September 2007 along four routes: north-west (NW; connecting Delhi/Ghaziabad, Ahmedabad, Kandla and Mumbai), north-south (NS; connecting Delhi/Ghaziabad and Bangalore), north-east (NE; connecting Delhi/ Ghaziabad and Kolkata) and south-east (SE; connecting Kolkata and Bangalore). Long-distance truckers in the present study were defined as truck drivers travelling to destinations more than 800 km from their point of origin. The definition used in the study was the same as used in the Kavach programme of Avahan, as the present study was a baseline for the Kavach programme [5]. Transporters and brokers of the trucking industry are middlemen, located at trans-shipment locations (TSL), who link truckers with individual organizations wanting their goods to be transported. The road transport industry in India works on a hub and spoke model, in which truckers transport goods between TSL at major cities, and from there goods for regional and/or local distribution are distributed to regional and local short-distance truckers for transportation onwards. This structure provided the basis for the sampling frame. Pre-survey assessments The first step in the study was a pre-survey assessment (PSA) to select study sites along the specific routes. The PSA began with an in-depth interview at TSL in New Delhi and Ghaziabad with transporters and brokers about issues such as truck volumes and movement patterns, generating an exhaustive list of 30 prospective study TSL. The list was subsequently reviewed by technical experts and key non-governmental organization (NGO) representatives working with truckers at the national level who understand the need for route wise representativeness of truckers on the specified routes. Accordingly, 20 TSL in nine locations on the specified four routes were chosen for more detailed PSA to short-list study TSL further. The detailed PSA required discussions with local transport stakeholders at each listed TSL. Detailed data were collected on the volume of long-distance truckers available, time spent at the TSL, and patterns of movement on a daily, weekly and monthly basis. The results were again discussed by technical experts and key NGO representatives working with truckers at the national level, to arrive at the geographical coverage in a way to ensure the representativeness of the long-distance truck drivers operating on any route category in India. As a result, seven TSL located in Delhi, Ghaziabad, Ahmedabad, Kandla, Mumbai, Bangalore and Kolkata corresponding to four routes were finally selected for the study for the main IBBA survey (see Fig. 1). Sampling frame development As truckers are a mobile group; time location cluster (TLC) sampling was used, which required a sampling frame. The sampling frame was developed in the seven selected TSL, by gathering detailed information from each transporter/broker (referred to as transport establishments) providing consignments to truck drivers. Transport establishments were asked about their profile (i.e. whether transporter or broker), days of operation/ closure, and minimum and maximum number of trucks dispatched on each route per day/week/month. The

3 Risk behaviour, HIV and sexually transmitted infections among truck drivers in India Pandey et al. S83 Bengali, Telgu, Tamil, Gujarati and Marathi), was used by native speakers to record data from eligible truckers at each TSL. The questionnaire collected information on demographics, work, mobility, sexual behaviour female sexual partners (wife, paid partner and non-paid partner), male sexual partners, hijra (i.e. transgender) sexual partners, condom, drug and injection practices, history and symptoms of STI, knowledge of HIV and its prevention and exposure to HIV prevention interventions, undertaken by Avahan and others. In this study exposure to intervention means using services (counselling, diagnostic, treatment, etc.) from Avahan (i.e. Khushi Clinic) or any NGO/programme providing similar services in the same geographical area. Fig. 1. Geographical coverage: routes and cities. Routes: NW: north-west (route joining the cities of Ghaziabad Delhi Ahmedabad Kandla Mumbai); NS: north-south (route joining the cities of Ghaziabad Delhi Bangalore); NE: north-east (route joining the cities of Ghaziabad Delhi Kolkata); SE: south-east (route joining the cities of Bangalore Kolkata). transport establishments during different time slots functioned as TLC for the study. There was a total of four sampling frames developed, one each for the four route categories, comprising TLC of the related TSL. Out of a total of 6278 TLC, in the four route categories, 1329 TLC were selected for the study. The TLC sampling among long-distance truck drivers had two stages; one in which the required number of TLC were selected by probability proportional to size from the sampling frame for each route, and a second stage, in which the required number of trucks were selected from the selected TLC, and subsequently the main truck drivers of selected trucks were approached for participation. Sample size A sample size of 500 long-distance truck drivers was used for each route, allowing for the detection of an absolute difference of 15% or more from the assumed value of 50% with 95% confidence and 80% power for indicators such as consistent condom use and last time condom use with paid partners. Data collection A pre-tested, pre-coded and mostly closed-ended questionnaire, translated into local languages (Hindi, Laboratory methods Blood and urine samples were collected from all participating truckers. Specimens were tested for HIV (two HIV serology tests), reactive syphilis serology (rapid plasma reagin confirmed by Treponema pallidum haemagglutination assay), Neisseria gonorrhoeae and Chlamydia trachomatis (target mediated amplification technique) and herpes simplex virus type 2 (HSV-2; in 10% of samples) (IgG serology). All cases with rapid plasma reagin reactive serology in any titre with T. pallidum haemagglutination assay positivity were considered positive. Full laboratory methods are detailed in another paper in this supplement. Ethical issues The study was approved by all relevant institutional review boards (Health Ministry Screening Committee, Government of India, Scientific Advisory Committee of NARI, Protection of Human Subjects Committee of Family Health International and Scientific Advisory Committee and Ethical Committee of National Institute of Medical Statistics). Participation followed written informed consent and all data were recorded in a linked anonymous manner, using numerically coded cards. Clinics run by the Transport Corporation of India Foundation at highway locations were used to enable participants to obtain syphilis test results and treatment upon presentation of the numerically coded cards. Data management and analysis The Census and Survey Processing System (CSpro) (version 3.3) was used for data entry, which was subsequently validated. IBBA used a two-stage sampling plan, in which clusters were selected at the first stage, followed by the selection of unequal number of respondents in the second stage to maximize the efficiency of the field teams. The sampling plan thus produced nonself-weighted samples, which resulted in potentially biased samples. The standard method for correcting unequal probabilities of selection was adapted to the validated datasets, by applying sampling weights during analysis. Two sets of sampling weights were computed, one route specific for route-wise dataset and the other was overall

6 S86 AIDS 2008, Vol 22 (suppl 5) 18 years, with the median age at first paid sex being 20 years. The reported consistent condom use with paid partners was approximately 70%; highest on the NS (73.6%) and lowest on the SE (64.3%). As far as never use of condoms with paid partners was concerned, 4.7% reported never using condoms; highest on the NE (17.7%) and lowest on the SE (1.8%). Over one-fifth (20.6%) of truckers reported having nonpaid sexual partners in the past 12 months, with 18.6% reporting consistent condom use. A small percentage (2.1%) of truckers reported having either male or hijra (transgender) sexual partners in the past 12 months. Almost all the currently married truckers (99.2%) reported having sex with their wives in the past 12 months but consistent condom use with wives was found to be low (3%). HIV and HIV risk perception and voluntary HIV testing Among the truckers who reported having ever heard about HIV/AIDS, only 9.9% felt that they might be at risk of HIV infection; it was highest on the NS (16.9%) and lowest on the NE (5.2%). Among those who reported that they might be at risk of HIV, 53.6% reported having paid partners in the past 12 months, 17.1% reported having non-paid partners in the past 12 months, and 17.5% reported not using condoms consistently with paid partners (P ¼ 0.270). It was found that only 16.5% of the truckers reported ever having undergone HIV testing; highest on the SE (33.5%) and lowest on the NE (8.9%). Exposure to interventions A quarter of the truckers reported exposure to any HIV prevention intervention; highest on the SE (38.4%) and lowest on the NW (15.1%) (Table 2). Biological results HIV prevalence was found to be 4.6% [95% confidence interval (CI) ]; highest among truckers on the SE (6.8%; 95% CI ), followed by the NW (3.7%; 95% CI ), NE (3.2%; 95% CI ) and NS (2.4%; 95% CI ). The prevalence of positive HSV-2 serology, undertaken in 10% of the sample, was 19.5% (95% CI ); ranging from 38.7% (95% CI ) on the SE to 6.7% (95% CI ) on the NW. Overall, reactive syphilis serology prevalence was 2.7% (95% CI ); lowest for the SE (1.2%; 95% CI ) and highest for truckers on the NE (3.8%; 95% CI ). The prevalence of other STI (gonorrhea and chlamydia) was low (<1%) on all routes (Table 2). Factors associated with having sex with paid partner On undertaking multiple logistic regression to determine factors associated with paying for sex, we found that truckers on the SE route were more likely to have sex with paid partners [odds ratio (OR) 2.37; 95% CI ; P ¼ 0.001) than the NE route (Table 3). Truckers aged years were more likely to pay for sex than both younger and older truckers (OR 1.96; 95% CI ; P < ). Similarly, currently not married truckers were more likely to pay for sex than those who were currently married (OR 2.09; 95% CI ; P < ). After controlling for the various background characteristics, however, the ability to read and write does not have any significant effect on the odds of having sex with paid female partners during the past 12 months; truckers were more likely to have sex with paid partners. Other factors significantly associated with paying for sex included average duration of one round trip and self-risk perception for HIV. Truckers spending an average of more than 10 days per round trip were more likely to pay for sex (OR 1.50; 95% CI ; P ¼ 0.06), whereas truckers who reported having a self-risk perception of HIV were more likely to pay for sex than those reporting that they were not at risk of HIV (OR 3.22; 95% CI ; P < ). Factors associated with using condoms consistently with paid partner Having undertaken logistic regression to determine factors associated with using condoms consistently with paid partners, few factors were found to be significant (Table 3). The truckers who owned trucks were more likely to use condoms consistently with paid partners than others (OR 4.56; 95% CI ; P ¼ 0.001). Truckers who had first paid sex after the age of 18 years, compared with those who had it by the age of 18 years, were more likely to use condoms consistently with paid female sex partners (OR 2.55; 95% CI ; P < ). Compared with truckers who had never been tested for their HIV status, truckers who had been tested were less likely to use condoms consistently with paid female sex partners (OR 0.42; 95% CI ; P ¼ 0.001) (Table 3). Factors associated with having any sexually transmitted infection On undertaking logistic regression to determine factors associated with having any STI, it was found that the truckers who drive trucks owned by their relatives/friends were more likelythan othersto have any STI(OR 4.33; 95% CI ; P ¼ 0.001). Truckers who had worked for more than 180 months were less likely than those who have workedfor upto60months tohave any STI (OR 0.05;95% CI ; P ¼ 0.008). Similarly, younger truckers (24 years old) were more likely to have any STI than relatively older truckers (aged 35 years and above) (OR 21.15; 95% CI ; P ¼ 0.005) (Table 3). Discussion This first-ever comprehensive cross-sectional survey among more than 2000 long-distance truckers in India

8 S88 AIDS 2008, Vol 22 (suppl 5) has important findings with policy implications. The study has its limitations, however, being representative of only the four specified routes. One of the biggest challenges in the study was to recruit truckers as a result of their mobile nature. Moreover, as the study was undertaken at the terminating cities/tsl of the selected routes, the truckers whose origination and destination would have been between the selected terminating cities/tsl may not have been included in the study. The refusals to participate in the study, non-availability of the selected truckers and the lack of time on the part of the selected truckers may have biased the selection of participating truckers. In the study, the median age of truckers was 30 years, with a range of years; similar to the findings of Baishali et al. [15], who reported the mean age of transport workers to be 31 years (range years) on the Siliguri Gawahati highway in India. In the study 13.5% of the truckers were not able to read or write, which was similar to the findings of the study of Baishali et al [15], which reported illiteracy of 28% among transport workers. The study by Bansal [22], however, among adolescent cleaners in Madhya Pradesh, India, reported the illiteracy level to be contrastingly high at 80%. It was found that illiterate truckers were more likely to have commercial sex than literate truckers. The present study and the studies by Baishali et al. [15] and Bansal [22] thus indicate that there is a need for interventions that can address both relatively literate truckers and illiterate helpers/cleaners. The truckers who owned the truck(s) that they drove (14.2%) were more likely to use condoms consistently with paid partners compared with the non-owners; and were less likely to have an STI. This thus suggests a positive correlation of safe sexual behaviour with economic and social wellbeing. As far as marital status was concerned, 73.8% of the truckers in the present study were found to be currently married, a rate similar to that reported in the study by Baishali et al. [15] (61.1%), and a similar study in Uganda [23] (63.7%). Compared with currently married truckers, those currently not married were more likely to report sex with paid partners. The currently married truckers were, however, found to have a higher prevalence of STI compared with those currently not married. In our study, 31% of the truckers reported having paid partners in the past 12 months and 70% reported using condoms consistently, whereas 4.7% reported that they never used condoms with paid partners. Similar studies, such as Baishali et al [15] in 2004 found that 67.4% of the transport workers had sexual contacts with sex workers and 71% were consistent condom users with sex workers, whereas in 2006 Chaturvedi et al. [24] found that 57% of long-distance truck drivers in India had paid for sex, and of these, 60% had never used a condom. In 2000, Manjunath et al. [25] found that 66% of truck drivers had visited sex workers and 60.5% had never used a condom. In 1992, Ahmed [26] found that 82% of truck drivers reported contact with sex workers and none reported using condoms. Chandrasekaran et al. [27] have recently noted the consistent long-term decline in unsafe commercial sex among truckers in Tamil Nadu. The findings of the present study of a relatively lower percentage of truckers reporting paid partners and a higher proportion reporting consistent condom use with paid partners thus show an improvement compared with similar earlier studies and suggest that HIV prevention activities among truckers have been succeeding. In our study, only 2.1% of the truckers reported having male or transgender partners in the past 12 months. Baishali et al. [15] also found that only 2% of 301 Indian truck drivers disclosed sexual contact with men while on a journey. Even though the percentage of truckers reporting sex with men or transgenders is quite low, which may be due to stigma, it is important to continue including information and counselling on male and transgender sex in interventions, as the risk of HIV transmission per sex act is much higher for anal sex than vaginal sex. Our study found that only one in every five truckers reported sex with non-paid partners over the past 12 months. The consistent condom use among those with non-paid partners was also reported to be low (18.6%). In contrast to non-paid partners, sexual relations with wives in the past 12 months were reported by almost all the currently married truckers, although consistent condom use with wives was reported by only 3% of the overall sample. This finding further suggests that the wives of currently married truckers act as a reservoir for STI. The important finding of the present study is the high HIV prevalence among truckers (4.6%; 95% CI ) over 12 times higher than that reported in the general male Indian population (0.36%) [1,20,28]. In contrast, positive syphilis serology was low (2.7%; 95% CI ), as were rates of both gonococcal and chlamydial infection (0.2%; 95% CI ) and (0.3%; 95% CI ), respectively. As indicated earlier, however, the STI varied across routes, and the SE had a unique feature in having relatively more truckers having paid partners (43.7%); undertaking HIV testing (33.5%); reporting exposure to interventions (38.4%); with HIV infection (6.6%); and with HSV-2 infection (38.7%); but fewer truckers with syphilis (1.2%) and fewer who never used condoms with paid partners (1.8%).

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